Ischaemic Stroke Occurring in a Patient Treated with Monoclonal Antibodies for COVID-19.

Since the COVID-19 outbreak began, an association between COVID-19 and thrombotic diseases has been underlined. Although this association is more frequent with venous thromboembolism, ischaemic stroke has also been reported as a thrombotic complication in several cohorts of affected patients. Furthermore, the association between ischaemic stroke and COVID-19 has been considered a risk factor for early mortality. On the other hand, after the successful vaccination campaign, the incidence and the virulence of SARS-CoV-2 decreased, though it has been observed that COVID-19 may induce a severe infection in specific cohorts of frail subjects. For this reason, different drugs have been introduced of an antiviral action in order to improve the disease outcome of frail patients. In this field, with the arrival of a neutralizing monoclonal antibody against SARS-CoV-2, in particular, sotrovimab, a further chance to treat high-risk patients with mild-to-moderate COVID-19 arrived, achieving a concrete reduction in the risk of disease progression. We here report our clinical experience of an ischaemic stroke occurring a few minutes after the administration of sotrovimab for the treatment of moderate COVID-19 in a frail patient with chronic lymphocytic leukaemia. Other causes of ischaemic stroke were ruled out, and in order to evaluate the probability of a rare side effect, the Naranjo probability scale has also been utilized. In conclusion, among several side effects that have been described during the treatment of COVID-19 with sotrovimab, ischaemic stroke was not reported. Therefore, we here report a rare case of ischaemic stroke with early clinical manifestation after the administration of sotrovimab for the treatment of moderate COVID-19 in an immunocompromised patient for the first time.

Real-time contrast-enhanced specific ultrasound in staging and follow-up of splenic lymphomas.

From January 2003 to April 2005 we studied 25 lymphoma patients (10 with HD, 4 with low-grade NHL, 6 with high-grade NHL and 5 with chronic lymphatic leukaemia; 14 men, 11 women, age range 28-79 years). After a baseline US study we rapidly injected 4.8 mL of the second-generation microbubble contrast agent SonoVue (Bracco, Italy). Contrast enhanced studies were carried out with the contrast-specific software named Contrast Tuned Imaging (Esaote, Italy) using a continuous, harmonic acquisition and a low acoustic pressure. The CS-US findings were correlated with results of standard tools, including CT, MRI, US follow up. CS-US revealed correctly 47 out of the 52 lesions identified by CT scan, in the absence of false positive findings (sensitivity = 90%; Specificity = 100%, in comparison to CT scan). Complete concordance in evaluating the lesion extension of the CS-US in respect to CT was 88%, while underestimate occurred in 9% and overestimate in 3% of cases. On the contrary, basic sonography defined correctly the dimensional alteration in 52% of the cases, underestimated in 35% and overestimated in 13%, thus showing significantly lower accuracy (chi-square = 30.0, p < 0.001). In our experience, CS-US was superior to conventional sonography even from a qualitative point of view.

Real-time harmonic contrast material-specific US of focal liver lesions.

Recent advances in contrast material-enhanced ultrasonography (US) mainly include (a) development of low-acoustic-pressure (low-mechanical-index) harmonic software, capable of obtaining real-time images without disrupting contrast material microbubbles, and (b) commercialization of new contrast media ("second-generation" contrast media), capable of producing intense echo signals in this low-mechanical-index setting. With use of low-mechanical-index continuous-mode contrast-enhanced US, the circulatory kinetic models of various focal liver lesions can be displayed dynamically. Hepatic lesions usually have typical perfusion characteristics and enhancement patterns through the various phases of parenchymal enhancement, which helps characterize lesions and, in most cases, allows definitive diagnosis, even among lesions that exhibit very similar baseline appearances. Because of the use of harmonic technologies at low emission frequencies, there is some loss of spatial resolution and overall image quality, typically resulting in a grainy appearance. In addition, lesion depth affects the detectability of vascularity to some degree in that poor signal arises from deep-seated lesions. Moreover, liver attenuation (eg, in patients with steatosis or chronic liver disease) further reduces the sensitivity of contrast-enhanced US. Nevertheless, with its unique capacity to provide images in real time, low-mechanical-index contrast-enhanced US is the dynamic imaging modality of choice in the differential diagnosis of focal liver lesions.

Blunt hepatic trauma: evaluation with contrast-enhanced sonography: sonographic findings and clinical application.

OBJECTIVE: The purpose of this study was to report our initial experience in the assessment of liver trauma with real-time contrast-enhanced sonography (CES). METHODS: From January 2000 to December 2003, there were 431 hemodynamically stable patients evaluated with sonography for blunt abdominal trauma. Among these patients, 87 were selected to undergo second-level imaging, consisting of CES and computed tomographic (CT) evaluation. Indications for further assessment were baseline sonographic findings positive for liver injury, baseline sonographic findings positive for injury to other abdominal parenchyma, baseline sonographic findings positive for free fluid only, baseline sonographic findings indeterminate, and baseline sonographic findings negative with persistent clinical or laboratory suspicion. RESULTS: There were 23 hepatic lesions shown by CT in 21 patients. Peritoneal or retroperitoneal fluid was identified in 19 of 21 positive cases by all 3 imaging modalities. Liver injury was found in 15 patients on sonography and in 19 on CES. Contrast-enhanced sonography compared better than unenhanced sonography with the criterion standard for related injury conspicuity, injury size, completeness of injury extension, and involvement of the liver capsule. Both CES and CT showed intrahepatic contrast material pooling in 2 cases. All patients with false-negative sonographic or CES findings recovered uneventfully. CONCLUSIONS: Contrast-enhanced sonography is an effective tool in the evaluation of blunt hepatic trauma, being more sensitive than baseline sonography and correlating better than baseline sonography with CT findings. In institutions where sonography is regarded as the initial procedure to screen patients with trauma, this technique may increase its effectiveness. In addition, CES may be valuable in the follow-up of patients with conservatively treated liver trauma.

Contrast-enhanced sonography for diagnosis of ruptured abdominal aortic aneurysm.

OBJECTIVE: We describe the contrast-specific sonography features of ruptured abdominal aortic aneurysm, and we hypothesize that this technique would be useful for emergency imaging of patients with suspected aneurysm rupture. CONCLUSION: We used contrast-specific sonography to assess eight patients with ruptured abdominal aortic aneurysm. Five of these cases were correlated with CT findings. We found that contrast-enhanced sonography can reveal features specific for ruptured aortic aneurysm without causing a significant delay in surgery. This technique may be as effective as CT but may allow a more rapid and noninvasive diagnosis, especially when sonography can be performed bedside.

Real-time, contrast-enhanced sonographic imaging in emergency radiology.

PURPOSE: To report our pilot experience in the evaluation of traumatic and nontraumatic emergencies with contrast-specific, continuous-mode sonography (US) and a second-generation contrast medium. MATERIALS AND METHODS: Between January 2002 and December 2003 we evaluated 126 acute patients by using real-time contrast-specific US: blunt abdominal trauma (76 cases), penetrating abdominal trauma (3), blunt scrotal trauma (1), right upper abdominal pain (10), left upper abdominal pain (9), epigastric pain (2), flank pain (5), right lower abdominal pain (2), scrotal pain (7), postoperative abdominal sepsis (1), post-biopsy haemorrhage (1), ruptured abdominal aortic aneurysm (8), postsurgical aortic bleeding (1). In all cases the radiologist performed a complete baseline US survey and then decided whether or not to add a contrast-enhanced examination. RESULTS: All contrast-enhanced sonographic studies were completed proving to be adequate for diagnostic purposes and without adverse reactions to contrast medium. There were 40 true negatives. The final diagnosis, obtained in 85 positive cases out of 86, was: splenic injury (28 cases), hepatic injury (3), renal injury (3), multiple injuries (3), pancreatic and portal vein injury (1), colonic-mesocolic injury (1), testicular trauma (1), hepatic abscess (9), hepatic ischaemia (1), gangrenous cholecystitis (1), splenic infarction (8), splenic haematoma abscess (1), renal infection (4), renal infarction (1), necrotizing pancreatitis (1), post-biopsy haemorrhage (1), appendicitis (2), peritoneal abscesses (1), testicular torsion (6), orchiepididymitis (1), iliac artery dissection (1), ruptured abdominal aortic aneurysm (6), aortic periprosthetic hemorrhage (1). Out of 85 positive cases, agreement between baseline US and contrast-specific US was absent in 8% of cases, low in 26%, intermediate in 42%, and high in 24%. Baseline US had 3 false positives. Relevance of contrast-specific US was absent in 17% of cases, low (additional data not relevant for patient management) in 26%, intermediate (relevant additional data not modifying patient management) in 34%, and high (additional data modifying patient management) in 23%. Agreement between contrast-specific US and the gold standards was absent in 0% of cases, low in 6%, intermediate in 38%, and high in 56%. Contrast-specific US had 2 false positive results. CONCLUSIONS: Real-time contrast-specific US is an effective technique in emergency imaging. Its role should not be considered as a replacement of CT (though in some instances it can be considered a valuable alternative) but as a useful integration of conventional US. By always having the opportunity to add contrast-enhanced imaging, in case of interpretation doubts or diagnostic difficulties, the radiologist can assess the emergency patient with improved confidence and skill.

Real-time contrast-enhanced ultrasound of the spleen: examination technique and preliminary clinical experience.

PURPOSE: To report our preliminary experience in the evaluation of the spleen using a real-time contrast-specific ultrasound module in combination with a second-generation contrast agent. MATERIALS AND METHODS: In a 7-month period, 55 patients (34 males and 21 females, aged 5-77 years) with spleen disorders were evaluated by means of contrast-enhanced ultrasound. Two patients were studied because of baseline evidence of an accessory spleen and both underwent ultrasound follow-up. Twenty-five patients were studied for abdominal trauma and results were correlated with those of helical CT. Three patients were examined for suspected splenic infarction and for all CT correlation was obtained. Finally, twenty-five subjects were examined for focal diseases, such as lymphomas (17 cases) and focal lesions (8 cases); contrast-enhanced US results were correlated with those of CT (8 cases), MRI (2 cases), ultrasound follow-up (8 cases), biopsy (2 cases) or splenectomy (1 case). After an initial baseline study, the contrast-enhanced examinations were carried out using a dedicated unit equipped with a continuous contrast-specific module at low acoustic pressure. The examination started immediately after rapid contrast injection and lasted approximately 4 minutes. In the comparison between baseline and contrast-enhanced ultrasound, the following aspects were considered: detection rate of parenchymal changes, lesion extent (equal to CT, under- or overestimated), and lesion conspicuity (lesion-to-parenchyma gradient, from 0 = absent to 3 = high). RESULTS: In the 2 patients with accessory spleen, an enhancement very similar to that of the adjacent parenchyma was present and a small vascular pedicle was noted. Among the trauma patients, 18 had a direct splenic injury and one showed splenic contraction and hypoperfusion due to shock. In 74% of cases, a peritoneal effusion was demonstrated both with baseline and contrast-enhanced ultrasound; perisplenic blood collections (58% of cases) were identified in 42% of patients by both baseline and contrast-enhanced ultrasound; post-traumatic infarction was always revealed by contrast-enhanced ultrasound (11% of cases) but never by baseline ultrasound; parenchymal injuries were detected with a sensitivity of 63% by baseline ultrasound and a sensitivity of 89% by contrast-enhanced ultrasound. Moreover, contrast-enhanced ultrasound revealed findings undetectable on conventional ultrasound: global splenic hypoperfusion in 2 cases (due to shock in one and pedicle avulsion in the other), intraparenchymal contrast collections in 21% of positive cases (as confirmed by CT), extrasplenic contrast leakage in 1 of 2 cases demonstrated by CT. Of the 3 cases of splenic infarction, baseline sonography only only identified two, whereas the contrast-enhanced examination clearly identified three. Contrast-enhanced ultrasound revealed 35 of 39 focal lesions in patients studied for Hodgkin's disease and splenic focal lesions. Baseline ultrasound had a lower sensitivity (23 lesions). Lesion extension shown by contrast-enhanced sonography was equivalent to that provided by standard methods in 88% of cases (underestimated in 9% and overestimated in 3%); baseline US correctly estimated lesion size in 52% of cases, under- and overestimating them in 35% and 13% of cases, respectively. Lesion conspicuity was graded as 1 (low) in 16%, 2 (moderate) in 67%, and 3 (high) in 17% of the cases identified by enhanced sonography. Baseline ultrasound was less effective: conspicuity was graded as 1 in 42%, 2 in 39%, and 3 in 19% of cases. CONCLUSIONS: The spleen is the ideal organ to be studied with second-generation contrast media due to its superficial location, high vascularity, small size and homogeneous texture. Contrast-enhanced ultrasound is a simple, poorly-invasive and accurate tool for the evaluation of splenic disorders. If our data are confirmed, it will be possible to reduce the use of more complex technologies such as CT and MRI.

Splenic trauma: evaluation with contrast-specific sonography and a second-generation contrast medium: preliminary experience.

OBJECTIVE: To report our experience in the assessment of splenic trauma with contrast-coded sonography and a second-generation contrast medium. METHODS: From January to May 2002, 120 patients were studied with sonography for suspected splenic trauma. Twenty-five were selected for further imaging because of sonographic findings positive for splenic injury, findings positive for peritoneal fluid only, indeterminate findings, and negative findings with high clinical or laboratory suspicion. These patients underwent contrast-enhanced harmonic sonography and contrast-enhanced helical computed tomography. RESULTS: Among the 25 patients studied, 6 had no spleen trauma at initial and follow-up evaluation. One patient had a hypoperfused spleen without parenchymal damage, and 18 had splenic injuries; these 19 patients were considered positive. Hemoperitoneum was identified by sonography, contrast-enhanced sonography, and contrast-enhanced computed tomography in 74% of the 19 positive cases. Perisplenic clots were recognized in 58% of the cases by computed tomography and in 42% by baseline and enhanced sonography. Splenic infarctions were found in 11% of cases by contrast-enhanced sonography and computed tomography; none was found by unenhanced sonography. Parenchymal traumatic lesions were identified in 12 of 18 patients with splenic injuries by unenhanced sonography, in 17 cases by contrast-enhanced sonography, and in all 18 cases by contrast-enhanced computed tomography. A minimal splenic lesion was found in the single patient with a false-negative contrast-enhanced sonographic finding. Contrast-enhanced sonography correlated appreciably better than unenhanced sonography in detecting injuries and in estimating their extent. Findings undetectable on unenhanced sonography were also noted: splenic hypoperfusion in 11% of positive cases on both contrast-enhanced sonography and contrast-enhanced computed tomography, contrast medium pooling in 21% of cases on both contrast-enhanced sonography and computed tomography, and contrast extravasation in 11% of cases on computed tomography and 5% on contrast-enhanced sonography. CONCLUSIONS: Contrast-enhanced sonography is a promising tool in the assessment of splenic trauma. In institutions where sonography is used as the initial procedure, this technique may increase its effectiveness.